Common use of Radiation Therapy/Chemotherapy Services Clause in Contracts

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% $300 per admission - After deductible Afterdeductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% $40 - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 020% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Inpatient 020% - After deductible Not Covered Outpatient 020% - After deductible Not Covered Skilled or sub-acute care 020% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 020% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 20% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 20% - After deductible Not Covered In a physician’s office 20% - After deductible Not Covered When rendered by our designated telemedicine provider. 020% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $20 Not Covered When rendered by our designated telemedicine provider. 0% - After deductible $35 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible Not Covered Inpatient physician services 010% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 010% - After deductible Not Covered In a physician’s office 0% - After deductible $20 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay When rendered by our designated telemedicine provider. 0% - After deductible $35 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible Not Covered Inpatient physician services 010% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 010% - After deductible Not Covered In a physician’s office 0% - After deductible $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay When rendered by our designated telemedicine provider. 0% - After deductible $40 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $20 - After deductible Not Covered When rendered by our designated telemedicine provider. 0% - After deductible $25 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $30 Not Covered When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered 20% - After deductible In a physician’s office 0% - After deductible Not Covered 20% - After deductible Inpatient 0% - After deductible Not Covered 20% - After deductible Outpatient 0% - After deductible Not Covered 20% - After deductible Skilled or sub-acute care 0% - After deductible Not Covered 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 040% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $15 20% - After deductible When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not CoveredSee the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Skilled or sub-acute care 10% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 10% - After deductible Not Covered Inpatient physician services 10% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 10% - After deductible Not Covered In a physician’s office $20 Not Covered When rendered by our designated telemedicine provider. 0% - After deductible $35 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered 20% - After deductible In a physician’s office 0% - After deductible Not Covered 20% - After deductible Inpatient 0% - After deductible Not Covered 20% - After deductible Outpatient 0% - After deductible Not Covered 20% - After deductible Skilled or sub-acute care 0% - After deductible Not Covered 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Inpatient physician services 020% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $20 20% - After deductible When rendered by our designated telemedicine provider. 0% - After deductible $50 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not CoveredSee the covered healthcare service being provided for the amount you pay

Radiation Therapy/Chemotherapy Services. Outpatient 010% - After deductible Not Covered In a physician’s office 010% - After deductible Not Covered Inpatient 010% - After deductible Not Covered Outpatient 010% - After deductible Not Covered Skilled or sub-acute care 010% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 010% - After deductible Not Covered Inpatient physician services 010% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 010% - After deductible Not Covered In a physician’s office 0% - After deductible $30 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Care Coordinated by Your Primary Care Provider and permitted Self-Referrals Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay When rendered by our designated telemedicine provider. 0% - After deductible $30 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered

Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered 40% - After deductible In a physician’s office 0% - After deductible Not Covered 40% - After deductible Inpatient 0% - After deductible Not Covered 40% - After deductible Outpatient 0% - After deductible Not Covered 40% - After deductible Skilled or sub-acute care 0% - After deductible Not Covered 40% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 020% - After deductible Not Covered Inpatient physician services 040% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office $10 40% - After deductible When rendered by our designated telemedicine provider. 0% - After deductible $20 Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not CoveredSee the covered healthcare service being provided for the amount you pay